South Central Region Presentation/Event Request Form

Thank you for your interest in learning more about Canine Companions for Independence. We try to accommodate as many presentation and event requests as possible but rely heavily on our volunteers, therefore, our ability to accommodate each request depends on our volunteer's schedules and the presentation location. We ask that you please submit your request at least 4 weeks in advance. Please keep in mind we are generally not able to confirm a presenter until two weeks before the date.

1.

Contact Information for Event Organizer

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Name:

First Required

Last Required

*

Email: Required

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Street 1: Required

Street 2:

*

City/State/ZIP:

City Required

State Required

ZIP Required

Required

*

Phone Number: Required

Yes, I would like to receive e-mail from Canine Companions for Independence

Yes, I would like to receive postal mail from Canine Companions for Independence